POSTPARTUM HAEMORRHAGE (PPH)

Postpartum haemorrhage (PPH) is one of the main causes of maternal death worldwide. It is
an obstetric emergency that needs to be managed promptly and effectively to reduce the risk
of morbidity and mortality.

DEFINITION AND INCIDENCE

PPH is defined as blood loss greater than 500mls and continuing. This definition is used as a
marker for audit and to mobilise extra resources. However, clinically significant PPH is more
usefully defined as any excessive bleeding that causes the woman to become symptomatic.

Primary PPH occurs in the first 24 hours postpartum and secondary PPH occurs 24 hours to 6
weeks after birth.

PPH is reported to occur after 1 to 5 % of births dependent on the criteria used to define PPH.

PREDISPOSING FACTORS

Although risk factors are a prompt to remain vigilant for PPH, in reality only a small
proportion of women with risk factors experience PPH. Possible predisposing factors include,
but are not limited to:
Antenatal Intrapartum
History of previous PPH Induction and/or augmentation
Large for gestational age newborn First stage labour >24 hours
(>4kg) Delay in progress of second stage
Placenta praevia/ accreta Precipitate labour
Hypertensive disorders Instrumental delivery
Obesity Caesarean section
High Parity Retained placenta
Bleeding disorders Lacerations
(based on UptoDate.com, 2010)
DIAGNOSIS

Blood loss tends to be underestimated which may delay active steps being taken to resuscitate
the woman and stop the bleeding. Women may lose up to a third of their blood volume
(1500-1800mls) without showing signs of shock.

Assessment of signs and symptoms is more clinically useful than blood estimation alone.
These include;
feeling unwell, lightheaded and/or fainting
pallor, cold peripheries and/or goosebumps
hypotension and/or tachycardia (occasionally bradycardia),
agitation and/or confusion.

W&CH/GL/M0021 Page 1 of 13 Date of Issue: March 2014

Authorised by Maternity Guidelines Group
 MANAGEMENT

Post Partum Haemorrhage Algorithm: Primary Unit

PPH >500ml ongoing

PPH box

Deliver placenta
Fundal massage (E) *
Expel clots
Baby to breast
Estimate blood loss Give uterotonic IV line
Pulse Empty bladder FBC
BP G&S

Bleeding continues and/or woman

symptomatic
Call 777 and ask for midwifery co-ordinator
Call 111 for ambulance
State location
State nearest crossroad
State Code One (lights & siren)

Check uterus is empty

Fundal massage (E) *
Expel clots
Catheterise bladder
Check placenta complete

Causes of bleeding Give oxygen

Tone Give Uterotonic Lie flat and/or head down
Tissue Oxytocin (Oxytocin)10 units IM
Trauma Or Oxytocin 5 units IV
Thrombin Or Syntometrine** 1ml IM

Start oxytocin infusion Give 1 litre 0.9% sodium

40 units Oxytocin in 500mls of 0.9% chloride (Normal Saline)
sodium chloride at 125mls/hr STAT
Assess blood loss
Continue IV fluids
Insert second IV line if
possible to increase rate
Other measures of IV fluids.
Indwelling Foleys catheter
Perform bimanual compression (*A)

Transfer to tertiary unit

*Refer to Appendices
**Avoid Syntometrine in women with hypertension or cardiac disease).
(Syntometrine contains oxytocin 5 units and ergometrine 0.5 mg in 1ml)

W&CH/GL/M0021 Page 2 of 13 Date of Issue: March 2014

Authorised by Maternity Guidelines Group
 Post Partum Haemorrhage Algorithm Tertiary Unit
PPH >500ml ongoing
Call 2nd midwife

Estimate blood loss Deliver placenta IV line

Pulse Fundal massage (E) * FBC
BP Expel clots G&S
Baby to breast
Give uterotonic
Empty bladder

Bleeding continues and/or woman symptomatic

ASSESS CALL FOR HELP RESUSCITATE

Red Emergency Bell
Get PPH Box

Estimate Blood Loss Insert second IV line

Document running total Give oxygen
STOP BLEEDING Lie flat/ head down

Check uterus is empty

Vital Observations
ABC
Pulse
BP
O2 sats/perfusion/RR
If cardiac/respiratory arrest is
imminent call a Clinical
Emergency immediately
Investigations
Check FBC, G&S sent
Arrange cross match
Coag screen
Fundal massage (E) *
Expel clots Rapid Crystalloid Infusion
Catheterise bladder 0.9% sodium chloride or compound
Check placenta complete sodium lactate (Hartmanns) 3 L
Give Uterotonic
Oxytocin (Oxytocin)10 units IM
Or Oxytocin 5 units IV Transfuse RBC
Or Syntometrine** 1ml IM Transfuse RBC when available.
After 3 litres crystalloid or if
cross matched RBC not
available consider O Neg
Start oxytocin infusion Consider Patient Specific
40 units in 500mls of 0.9% sodium Emergency Blood Box
chloride at 125mls/hr

Causes of bleeding Control bleeding from lower genital

Tone tract trauma
If haemorrhage exceeds 2000ml
Tissue
and/or patient shock activate
Trauma
Massive Transfusion Protocol.
Thrombin If bleeding continues
http://cdhb.health.nz/Hospitals-
Bimanual compression (A)*
Services/Health-
Call obstetric and anaesthetic consultants
Professionals/CDHB-
Transfer to theatre for definitive measures
*Refer to Appendices Policies/Fluid-Medication-
**Avoid Syntometrine in Manual/PublishingImages/Pag
women with hypertension or es/default/Adult-Massive-
cardiac disease). IF uterine atony continues consider Transfusion-Protocol.pdf
(Syntometrine contains Carboprost (Prostin / 15M ) 250 micrograms IM Ring Blood Bank (ext 80310)
oxytocin 5 units and ergometrine or intramyometrially, max 8 doses 15 min apart. and say I am activating the
0.5 mg in 1ml) Misoprostol 800 micrograms PR once only Massive Transfusion Protocol
Call for additional assistance
Obstetric Consultant
Anaesthetic Consultant
W&CH/GL/M0021 Page 3 of 13 Date of Issue: March 2014
Authorised by Maternity Guidelines Group
 Transfer to OT
Assessment and resuscitation measures continue as in the tertiary unit algorithm above.

Declare the emergency

Update team members
Identify leader
Use ISBAR

Examination under anaesthetic:

Lower genital tract including cervix for trauma (suture)
Manual removal of clots / placental tissue from uterus
Broad Spectrum IV Antibiotics
Correct Coagulopathy
Keep the patient warm

Uterotonic as Required:
Caesarean Section Continue Oxytocin infusion
Carboprost
Misoprostil

Uterine Tamponade Balloon*

(See Appendix B)

* NB B-Lynch and
Laparotomy in (modified lithotomy) (See Appendix C& D): tamponade balloon can
B-Lynch suture* be used together. If
Other uterine compression sutures using this option place
the balloon first,
perform B Lynch
suture, close uterus and
then inflate balloon

Call Gynae Oncologist

Arterial ligation. (See Appendix E):

Uterine
Internal iliac

HYSTERECTOMY. Consider subtotal as has less morbidity

W&CH/GL/M0021 Page 4 of 13 Date of Issue: March 2014
Authorised by Maternity Guidelines Group
 POSTNATAL CONSIDERATIONS

The frequency of observations will be guided by Obstetric team. Observations include:

Pulse
Blood pressure
Vaginal loss
Palpation of fundal tone and height

Blood loss 500-1500ml

2 sets of observations 15 minutes apart
2 sets of observations 30 minutes apart
Hourly observations until transferred out of birthing suite.
Women who have experienced blood loss in excess of 1000ml will usually stay on
birthing suite until 2 hours post Oxytocin infusion.

Blood loss that necessitates admission into Acute Observation Unit (AOU):
Frequency of observations as directed by the Obstetric team
Fluid balance - hourly urine output
Oxygen saturations
Further investigations as directed by Obstetric team

On arrival to maternity postnatal ward fill in an Allied Health CWH Inpatient Referral Form
C240029 to Dietitian for post partum haemorrhage if Hb <100g/L. Dietitian to provide advice
on iron rich diet, iron supplements, and healthy eating for breastfeeding women. If women
are on ward during out of hours cover the following resources are available; Thousands of
women dont get enough iron, Vegetarian food sources or Iron W&CH/Ref/849, Eating for
Healthy Breastfeeding Women.

Refer to Appendix B for directions on removal of uterine tamponade balloon

Refer to Postpartum Intravenous Iron Infusion Guideline (W&CH/GL/M/0012) if required.

REFERENCES

Crafter, H.
2002
Intrapartum and Primary Postpartum Haemorrhage
In Boyle, M. (ed.)
Emergencies around Childbirth
Radcliffe Medical Press: Oxford

Thorogood, C. and Hendy, S.

2006
Life-Threatening Emergencies
In Pariman, S., Pincombe, J., Thorogood, C. and Tracy, S.
Midwifery: Preparation for Practice
Elsevier: Marrickville

Jacobs, A.
2010
Causes and Treatment of Postpartum Haemorrhage
Downloaded from UpToDate.com on 8/6/10

W&CH/GL/M0021 Page 5 of 13 Date of Issue: March 2014

Authorised by Maternity Guidelines Group
 APPENDIX A - TEMPORARY MEASURES TO CONTROL HAEMORRHAGE

Uterine Fundal Massage:

Internal Bimanual Compression:

Compression of the Aorta:

Remember the bifurcation of the aorta is at the level of the sacral, promontory so press above
this.

Above diagrams from; Boyle M. Emergencies Around childbirth. Chapter 10

W&CH/GL/M0021 Page 6 of 13 Date of Issue: March 2014

Authorised by Maternity Guidelines Group
 APPENDIX B - INTRAUTERINE (BAKRI) TAMPONADE
BALLOON INSERTION METHOD

Diagram from Bakri et al.

Post vaginal birth:

Place woman in lithotomy (Lloyd Davis legs / yellow fins) and insert indwelling urinary
catheter into bladder
Attach a urine collection bag to the tamponade balloon silicone catheter (to collect the
draining blood)
Attach a 3 way tap to the balloon inflation port
Feed the balloon up through the cervix (proximal end)
Blow the balloon up with 250 to 500ml normal saline, until tamponade is achieved (place
fluid to be used in a separate container do not rely on syringe count)
Check balloon is correctly sited completely through internal os by digital palpation and/
or ultrasound scan. See diagram below (from Cook/ Obex product info).

Use a firm vaginal pack to stop the balloon falling out when it is put under tension (see
below). This may require 2-3 packs tied together after a vaginal birth
Attach a weight (500ml normal saline) to the distal end of the balloon catheter shaft or
alternatively tape it to patients legs to provide counter traction and put pressure on the
lower segment
Check for success. Move to other surgical options if unsuccessful. Discuss with Team

W&CH/GL/M0021 Page 7 of 13 Date of Issue: March 2014

Authorised by Maternity Guidelines Group
Post Caesarean Birth:
This technique is most useful for bleeding from the lower segment i.e. placenta praevia.
Place in frog leg position or lithotomy with Lloyd Davis legs (yellow fins)
Feed the distal end of the balloon catheter down through the cervix to an assistant who
pulls it through from below. Assistant attaches urine collection bag to balloon catheter
and 3 way tap to inflation port
If using in conjunction with a B-Lynch suture. Place the B Lynch suture at this point
Close the uterus (Bakri recommends to complete the Caesarean Section then you would
need to reopen if not successful)
Place a vaginal pack using a speculum
Blow the balloon up with 250 to 500ml normal saline
Attach a weight (500ml normal saline) to the distal end of the balloon catheter shaft or
alternatively tape it to patients legs to provide counter traction to put pressure on the
lower segment
Check for success. Move to other surgical options if unsuccessful. Discuss with Team

Removal:
Deflate balloon. In majority of cases 4-6hrs of tamponade should be adequate to achieve
haemostasis. Maximum recommended treatment time is 24 hours.
Ideally remove during the day hours in the presence of appropriate senior staff. Before
removal balloon should be deflated but left place for 1-2hours ensure bleeding does not
reoccur.

References;
1) Int J Gyn Obs. Bakri et al. Tamponade balloon for obstetrical bleeding. vol 74(2001)
139-142.
2) SOS Bakri Tamponade Balloon. Cook/ Obex. Product information

W&CH/GL/M0021 Page 8 of 13 Date of Issue: March 2014

Authorised by Maternity Guidelines Group
 APPENDIX C - METHOD FOR B LYNCH
UTERINE COMPRESSION / BRACE SUTURE

Use the suture from the box labelled B Lynch/ PPH available from store room
between CS theatres (large blunt curved round bodied hand held needle with extra long
vicryl suture. (Johnson and Johnson W9391)
Please refer to diagrams and note the following points;
1. Start 3cm below and medial to the right incision angle
2. Get your assistant to compress the uterus as much as possible during the procedure
3. Tighten the suture as you go i.e. when the first half of the pair of braces is placed
tighten at this point and get your assistant to hold it tight
4. The suture goes through the full thickness of the myometrium posteriorly
5. Compress the uterus further by tightening the suture more when you tie it.

Diagrams from original article by, Christopher B Lynch et al. The B-Lynch Surgical
Technique for the control of Massive Post partum haemorrhage. BJOG March 1997, Vol.
104, pp 372-375.

W&CH/GL/M0021 Page 9 of 13 Date of Issue: March 2014

Authorised by Maternity Guidelines Group
 Method for Brace Suture Post Vaginal Birth:
B- Lynch recommends opening and evacuating the uterus as for Caesarean, however an
alternative is shown below without opening the uterus which may be appropriate if a
thorough EUA has been performed from below.

As the uterus has not been opened modification of technique is required as shown in
diagram below; the brace sutures are placed separately through the full thickness of the
uterus and tied at the fundus on each side. Further compression sutures can be placed in the
lower segment.

Diagram from ; Tamizian O, Arulkumaran S, The surgical management of postpartum

haemorrhage.Best Practice and Research clinical O&G Vol. 16, No. 1, pp81-98. 2002.

W&CH/GL/M0021 Page 10 of 13 Date of Issue: March 2014

Authorised by Maternity Guidelines Group
 APPENDIX D - OTHER UTERINE COMPRESSION SUTURES

Other surgical techniques to appose the uterine walls are shown below.

Lower segment vertical compression sutures:

Above diagrams from; HWU et al, Parallel vertical compression sutures: a technique to
control bleeding from placenta praevia or accreta during caesarean section. BJOG Oct 2005,
Vol. 112, pp1420-1423.

Multiple square suture method:

Above diagram from ; Tamizian O, Arulkumaran S, The surgical management of postpartum

haemorrhage.Best Practice and Research clinical O&G Vol. 16, No. 1, pp81-98. 2002.

W&CH/GL/M0021 Page 11 of 13 Date of Issue: March 2014

Authorised by Maternity Guidelines Group
 APPENDIX E - METHODS OF ARTERY LIGATION

Uterine Artery Ligation:

This technique can be used by an Obstetrician familiar with uterine artery ligation during
total abdominal hysterectomy, location as shown below. In view of the large collateral
supply this procedure preserves the uterus. Ligation of the Utero ovarian anastamoses can
also be attempted.

Diagram from; Tamizian O, Arulkumaran S, The surgical management of postpartum

haemorrhage. Best Practice and Research clinical O&G Vol. 16, No. 1, pp81-98. 2002.

W&CH/GL/M0021 Page 12 of 13 Date of Issue: March 2014

Authorised by Maternity Guidelines Group
Internal Iliac Artery Ligation:
NB; this should only be attempted by a surgeon skilled in this technique e.g. Gynae
Oncologist, Vascular Surgeon. See diagram

Diagram from; Tamizian O, Arulkumaran S. The surgical management of postpartum

haemorrhage. Best Practice and Research clinical O&G Vol. 16, No. 1, pp81-98. 2002.

W&CH/GL/M0021 Page 13 of 13 Date of Issue: March 2014

Authorised by Maternity Guidelines Group